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I read with interest the results of the paper by Giustino et al. (1) to evaluate the safety and efficacy of new-generation drug-eluting stents in women undergoing complex percutaneous coronary artery revascularization. I wish to congratulate the investigators on undertaking this piece of work in such a large cohort (n = 10,241) to help us improve our understanding of the outcomes of percutaneous coronary intervention in women. I was particularly encouraged to see improved results for newer drug-eluting stent platforms in terms of reducing major adverse cardiac events (defined as the composite of all-cause mortality, myocardial infarction, and target lesion revascularization at 3 years).

However, one of the concerns when treating women is the risk for bleeding, particularly when faced with patients who may be older and of relatively low weight compared with their male counterparts. This is reflected in bleeding risk predictor scores, which include female sex as an important predictive factor (2,3). Indeed, female sex carries even more weight in these validated scores than baseline anemia. Importantly, previous work suggests that even if data are adjusted to take into account age, body mass index, and type of antithrombotic therapy, female sex remains an independent predictor of bleeding (4). Furthermore, the investigators quite correctly state that women are at increased risk for problems such as access-site complications, but they do not provide us with the rate of occurrence of such events in their population.

As the investigators are well aware, the occurrence of bleeding after coronary intervention increases the risk for death and, importantly, is associated with not insignificant morbidity (5). This is important because of the effect on quality of life as well as the cost implications of a prolonged hospital stay. It is therefore difficult to fully appreciate the results presented in this present study when taken in such isolation. The inclusion of safety information about major adverse bleeding events should be described as a fundamental part of studies of this nature.

Footnotes

Please note: Dr. Hoye has reported that she has no relationships relevant to the contents of this paper to disclose.